Needlestick injuries continue to cause problems among healthcare
workers. The Nuffield Hospitals’
evaluation of a selection of devices weighs up the benefits and costs of some
on the market, by Andrea Mummery
The aim of this article is to share with readers an exercise that was
carried out at Nuffield Hospitals to evaluate safer needle devices. The article
discusses the reasons why the project was undertaken, the process used, some of
the problems encountered and the results of the trial.
Over the past few years there has been a significant increase in the number
of companies marketing safer needle systems, designed to reduce the incidence
of needlestick injuries. Nuffield Hospitals, which consists of 43 private
hospitals across the UK, has carried out an exercise to evaluate a range of
products to determine which, if any, could enhance the safety of current
practice.
Introduction
Accidental exposure to blood and body fluids is a common occurrence among
healthcare workers. Transmission of blood-borne viruses such as hepatitis B,
hepatitis C and HIV may occur if a healthcare worker is exposed to infected
blood following a sharps injury or through splashing of infected blood onto
open wounds or mucous membranes.
The sero-conversion rate post-needlestick injury from a positive source is:
– Hepatitis B – 30 per cent
– Hepatitis C – 3 per cent
– HIV – 0.03 per cent1
Legal context
In America, the US Senate passed the Needlestick Safety and Prevention Act
in November 2000. This requires employers to introduce safer medical devices
and maintain a detailed sharps injury record2. Although there is no such
specific legislation in the UK, the Management of Health and Safety at Work
Regulations 1999 require employers to carry out risk assessments for all
identifiable hazards. The COSHH regulations 1999 specifically require
biological hazards to be assessed and appropriate control measures to be put in
place.
Unison argues that risk assessments for biological hazards, which do not
take into account safer devices, are not suitable and sufficient and would
therefore not meet legal requirements. The union is in discussion with the
Department of Health and the HSE regarding this point, which, if adopted, would
make the consideration of safety devices a statutory requirement in the UK3.
Selection criteria
A small working party, led by Nuffield’s OH manager, was set up to assess
the range of products on the market and agree which products to trial.
The working party recognised that Nuffield Hospitals already have a number
of measures in place to reduce the incidence of needlestick injuries, such as
blunt suture needles, and this trial therefore specifically focused on areas
where safer devices had not previously been available.
Seven suppliers were invited to demonstrate their products. The products
were then grouped into three main categories:
– Intramuscular injection
– Venepuncture systems
– Cannulation systems
Up to three products in each category were selected for the trial. In making
the selection, the following safety points were considered:
– If the safety feature was an integral part of the device and not an
accessory
– If it could be operated with one hand
– If the device allowed the healthcare worker’s hands to remain behind the
needle at all times
– If the the product had all the features required for its intended use
– If the product appeared straightforward to use
– How much the product cost
No products were excluded from the trial based on cost alone. However, some
were excluded because the device did not meet all the features required and
they were expensive, such as not being possible to change the needle during
intramuscular injection. This would in some circumstances require a patient to
be injected twice, if, for example, an analgesic and an anti-emetic are needed
post-operatively.
The process
Ten hospitals were asked to trial the syringes/needles for intramuscular
injection, 10 different hospitals were asked to trial the venepuncture systems,
and a further 10 to assess the cannulation devices.
A trial schedule was developed and circulated to both the hospitals and
company representatives. The representatives were responsible for arranging to
visit the hospitals and for teaching the staff how to use their products.
Each hospital was asked to nominate a liaison nurse whose role was to:
– Be a point of contact for the representatives and to co-ordinate training
on site
– Actively encourage the use of the devices during the trial and to be a
point of contact for staff in case they had any queries
– Assist with training staff unable to attend the company-led training
– Issue the evaluation forms to staff, collect them in at the end of each
trial and forward them to the OH manager
Each device was to be used for a period of up to two weeks and as many staff
as possible encouraged to try them. Each person who used the product was asked
to complete an evaluation form.
Challenges
As with most projects of this scale there were a number of challenges during
the trial. The key ones included ensuring information about the project was
disseminated properly through the hospitals, and co-ordinating the trial.
The co-operation of the matron and liaison nurse was vital. Frequently,
start dates of trials had to be altered due to staff holidays, clinical
workload and availability of the company representatives. This made keeping
track of the trial very difficult.
All the safety devices being trialled were significantly more expensive than
the standard products (at least double and sometimes three times the cost of
standard products). So the purchasing department negotiated with each supplier
to provide the product free or at a nominal cost for the duration of the trail,
highlighting the benefit to them of receiving independent feedback and the
possibility of further orders if clinicians liked the product. However, despite
agreeing a nominal charge, one or two companies consistently sent invoices to
hospitals.
The products selected for the venepuncture trial were not compatible with
the blood collection systems used in some of the hospitals. Three hospitals
therefore had to withdraw from this trial.
Two needlestick injuries occurred during the trial. One involved an
intramuscular device where the safety mechanism failed, the other occurred
while using a cannulation device. Appropriate follow-up action was taken after
each incident and the companies concerned carried out tests on the remainder of
the batch
Following the first accident the company strengthened the product to prevent
a recurrence. The second incident occurred due to poor technique, which
demonstrated the importance of adequate training.
There was considerable resistance from some of the doctors to trying out the
new cannulation products, which may need to be taken into account if a decision
is being made about whether the use of safer products is to be made compulsory.
Many hospitals were very slow or failed to return completed and evaluation
forms to the OH manager and a significant amount of time was spent chasing
hospitals. At the end of the trial, some hospitals had still failed to return
evaluation forms despite having used the products. This means these hospitals
lost the opportunity to influence which products will be introduced.
Occasionally forms were not completed properly, thus reducing their value.
The question most frequently left unanswered was the quantity that the user
trialled. If a form was returned with this question blank it was assumed to be
only one. The actual volume of product trialled was significantly higher than
is reflected in the evaluation results.
Results
Each evaluation form received was scored on the following points. All
questions had a score rating from one to five, with one being the best.
Therefore the lower the overall score the better the product was considered to
be. The following statements were rated:
– The packaging is clearly labelled
– The packaging allows easy access to the product
– The device is easy to prepare for use
– The safety feature does not impair vision or hamper the clinical procedure
– The safety feature can be activated using a one-handed technique
– The safety feature was easy to use
– The safety feature operates reliably
– There is a clear and unmistakable change that occurs when the safety
feature is activated
– The exposed sharp is permanently blunted or covered after use and prior to
disposal
– The user does not need extensive training in the use of the device
– The user was given appropriate training in the use of the device prior to
use
– They would be happy to use this device if it was a standard product
– Taking all things into consideration, how they would you rate the product
overall
Staff were also encouraged to make any additional comments, which were then
grouped into the following categories:
– Praise: design/use of the device, for example that the gauge was difficult
to read or leakage occurred
– Safety: the safety feature got in the way or was difficult to operate with
one hand, for example
– Non-specific negative comments such as ‘I don’t like this product’
– Other: expensive, would need more training and so forth
Perhaps not surprisingly the comments were mostly critical, although in many
cases constructively so. Staff who liked a product tended to score it highly
and not make additional remarks.
The products that received a good evaluation and their scores are shown in
the table above.
Discussion
All of the safer devices are considerably more expensive than the standard
equivalents and this is clearly a serious concern for hospitals with already
over-stretched budgets. However the increase in costs needs to be balanced by
the, often hidden, costs of managing a needlestick injury. In addition to the
financial costs, the emotional impact on staff is significant and must also be
taken into account.
It is estimated that a low risk needlestick injury will cost approximately
£450 to manage. This figure is based on laboratory charges, lost time for the
injured worker, and the time spent by managers and OH staff in following up the
incident. This cost increases to over £4,000 if there is a high risk of HIV or
hepatitis C (or both) and post-exposure prophylaxis and referral to a
specialist is required.
However, should a healthcare worker actually acquire a blood-borne virus
through occupational exposure, compensation awards would far outweigh the
increase in costs.
Recommendations
As a result of this work a number of recommendations have been made and are
now being considered by the senior management team. These include adding the
recommended products to the standard purchasing list and actively encouraging
their use in all our hospitals. There is a risk that if their use is not
compulsory, staff will continue to use the standard devices with which they are
already familiar. However, by ensuring that they receive adequate training and
by seeking the support of hospital managers and matrons it is hoped that safer
devices will become the standard choice.
Accidents will be carefully analysed to determine how they have occurred and
to determine how the accident could have been prevented.
Consideration will be given to making the use of safety devices compulsory
at a later date if the current measures are not effective in reducing injuries.
Other actions that will result from this work include improving the
needlestick accident recording system with consideration given to linking in
with EPINet4, a software system created specifically for the purpose of
recording and analysing occupational exposure to blood-borne viruses. The
software is designed to monitor sharps injuries and the consequences of such
exposures. EPINet is currently being used by the Royal College of Nursing as
part of its campaign to collate national statistics on needlestick injuries.
Other recommendations include:
– Revising the company sharps policy to include a section on prevention of
needlestick injuries
– Revising the company COSHH assessment for biological agents to include
safer needles devices as one of the control measures
– Promoting the use of other safety devices already available such as blunt
suture needles, plastic blood bottles, portable sharps boxes, etc
– Evaluating any new products that come onto the market
Conclusion
The sharps trial has been a positive exercise that has actively sought
solutions to a very real risk. The support of senior managers in introducing
this initiative is essential and they must be encouraged to promote a safe
culture at work and help their staff to embrace change.
This work will continue to monitor sharps injuries and explore additional
methods of reducing the incidence of injuries and promoting a safe working environment.
References
1. UK Health Department (1998) Guidance for Clinical Health Care Workers:
Protection Against Blood-borne Viruses. Recommendations of the Expert Advisory
Group on Aids and the Advisory Group on Hepatitis. London: Department of Health.
2. US Congress (2000) Needlestick Safety and Prevention Act. 106th Congress
of the USA.
3 UNISON (2000) Evaluating Safer Needles: Needle Safety at Work.
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4 University of Virginia (2000) EPINetª for Microsoft Access. Exposure
Prevention Information Network. EPINet is a trademark of the University of
Virginia. Becton Dickinson and Company.
Andrea Mummery is OH Manager at Nuffield Hospitals and a member of the
RCN OH Managers Forum
